Comparison of the duration of hospital stay after laparoscopic or open distal pancreatectomy: randomized controlled trial.

BACKGROUND: Studies have suggested that laparoscopic distal pancreatectomy (LDP) is advantageous compared with open distal pancreatectomy (ODP) regarding hospital stay, blood loss and recovery. Only one randomized study is available, which showed enhanced functional recovery after LDP compared with ODP. METHODS: Consecutive patients evaluated at a multidisciplinary tumour board and planned for standard distal pancreatectomy were randomized prospectively to LDP or ODP in an unblinded, parallel-group, single-centre superiority trial. The primary outcome was postoperative hospital stay. RESULTS: Of 105 screened patients, 60 were randomized and 58 (24 women, 41 per cent) were included in the intention-to-treat analysis; there were 29 patients of mean age 68 years in the LDP group and 29 of mean age 63 years in the ODP group. The main indication was cystic pancreatic lesions, followed by neuroendocrine tumours. The median postoperative hospital stay was 5 (i.q.r. 4-5) days in the laparoscopic group versus 6 (5-7) days in the open group (P = 0·002). Functional recovery was attained after a median of 4 (i.q.r. 2-6) versus 6 (4-7) days respectively (P = 0·007), and duration of surgery was 120 min in both groups (P = 0·482). Blood loss was less with laparoscopic surgery: median 50 (i.q.r. 25-150) ml versus 100 (100-300) ml in the open group (P = 0·018). No difference was found in the complication rates (Clavien-Dindo grade III or above: 4 versus 8 patients respectively). The rate of delayed gastric emptying and clinically relevant postoperative pancreatic fistula did not differ between the groups. CONCLUSION: LDP is associated with shorter hospital stay than ODP, with shorter time to functional recovery and less bleeding. Registration number: ISRCTN26912858 ( www.isrctn.com).

ANTECEDENTES: Los estudios han sugerido que la pancreatectomía distal laparoscópica (laparoscopic dital pancreatectomy, LDP) resulta ventajosa en comparación con la pancreatectomía distal por vía abierta (open distal pancreatectomy, ODP) respecto a la estancia hospitalaria, pérdida sanguínea y recuperación. Solamente existe un estudio aleatorizado que muestra una mejor recuperación funcional después de la LDP en comparación con la ODP. MÉTODOS: En un ensayo de superioridad unicéntrico, abierto y de grupos paralelos, los pacientes consecutivos evaluados por el comité multidisciplinario de tumores y a los que se indicó una pancreatectomía distal estándar fueron asignados al azar de forma prospectiva a LDP o ODP. El resultado primario fue la estancia hospitalaria postoperatoria. RESULTADOS: De 105 pacientes evaluados, 60 fueron aleatorizados, de los cuales 58 pacientes (24 mujeres; 41%) fueron incluidos y asignados a LDP (n = 29; edad media 68 años) o ODP (n = 29; edad media 63 años) e incluidos en un análisis por intención de tratamiento. La principal indicación fueron las lesiones quísticas del páncreas seguida de los tumores neuroendocrinos. La estancia hospitalaria postoperatoria fue de 5 días (rango intercuartílico, interquartile range, IQR 4-5) en el grupo laparoscópico versus 6 (5-7) días en el grupo de cirugía abierta (P = 0,002). La recuperación funcional se alcanzó después de 4 (2-6) versus 6 (4-7) días (P = 0,007), y el tiempo operatorio fue de 120 minutos en ambos grupos (P = 0.48). Las pérdidas hemáticas fueron menores en la cirugía laparoscópica, 50 (25-150) versus 100 mL (100-300) (P = 0,018). No se hallaron diferencias en las tasas de complicaciones (grado Clavien-Dindo ≥ 3) con 4 versus 8 pacientes en el grupo laparoscópico y en el grupo abierto, respectivamente. La tasa de retraso en el vaciamiento gástrico y de fístula postoperatoria clínicamente relevante no difirió entre los grupos. CONCLUSIÓN: La pancreatectomía distal laparoscópica se asocia con una estancia hospitalaria más corta en comparación con la cirugía abierta, con un menor tiempo para la recuperación funcional y menos hemorragia.

Serum amino acid profile in patients with acute pancreatitis.

Patients in the early phase of acute pancreatitis (AP) have reduced serum levels of arginine and citrulline. This may be of patho-biological importance, since arginine is the substrate for nitric oxide, which in turn is involved in normal pancreatic physiology and in the inflammatory process. Serum amino acid spectrum was measured daily for five days and after recovery six weeks later in 19 patients admitted to the hospital for acute pancreatitis. These patients had abnormal levels of most amino acids including arginine, citrulline, glutamine and glutamate. Phenylalanine and glutamate were increased, while arginine, citrulline, ornithine and glutamine were decreased compared to levels after recovery. NO(2)/NO(3) concentration in the urine, but not serum arginase activity, was significantly increased day 1 compared to day 5 after admission. Acute pancreatitis causes a disturbance of the serum amino acid spectrum, with possible implications for the inflammatory process and organ function both in the pancreas and the gut. Supplementation of selected amino acids could possibly be of value in this severe condition.

Multivisceral Resection in Patients with Advanced Abdominal Tumors.

BACKGROUND/AIM: Multivisceral resection for advanced tumors can result in prolonged survival but may also increase the risk of postoperative morbidity and mortality. The primary aim of this study was to investigate whether extensive resections increase the severity of postoperative complications. MATERIALS AND METHODS: A retrospective study was conducted between 2009 and 2014 at the Linköping University Hospital surgical department. All patients with a confirmed or presumed malignant disease who underwent a non-standardized surgical procedure requiring a multivisceral resection were included. The primary endpoint was 90-day complications according to the Clavien-Dindo score. RESULTS: Forty-eight patients were included, with an age range of 17-77 years. A median of three organs was resected. The most common diagnoses were neuroendocrine tumor (n = 8), gastric cancer (n = 7), and gastrointestinal stromal tumor (n = 6). One patient died during surgery. Complications ⩾ grade 3b according to Clavien-Dindo score occurred in 10 patients. R0 resection was achieved in 32 patients. No correlation was observed between the number of anastomoses, perioperative blood loss, operative time, and complications. Only postoperative blood transfusion was correlated with severe complications (p = 0.046); however, a tendency toward more complications with an increasing number of resected organs was observed (p = 0.06). CONCLUSION: Multivisceral resection can result in R0, potentially curing patients with advanced tumors. Here, no correlation between extensive resections and complications was observed. Only postoperative blood transfusion was correlated with severe complications.

Associating Liver Partition and Portal Vein Ligation for Primary Hepatobiliary Malignancies and Non-Colorectal Liver Metastases.

BACKGROUND AND AIMS: Associating liver partition and portal vein ligation for staged hepatectomy may increase the possibility of radical resection in the case of liver malignancy. Concerns have been raised about the high morbidity and mortality associated with the procedure, particularly when applied for diagnoses other than colorectal liver metastases. The aim of this study was to analyze the initial experience with associating liver partition and portal vein ligation for staged hepatectomy in cases of non-colorectal liver metastases and primary hepatobiliary malignancies in Scandinavia. MATERIALS AND METHODS: A retrospective analysis of all associating liver partition and portal vein ligation for staged hepatectomy procedures performed at two Swedish university hospitals for non-colorectal liver metastases and primary hepatobiliary malignancies was performed. The primary focus was on the safety of the procedure. RESULTS AND CONCLUSION: Ten patients were included: four had hepatocellular cancer, three had intrahepatic cholangiocarcinoma, one had a Klatskin tumor, one had ocular melanoma metastasis, and one had a metastasis from a Wilms' tumor. All patients completed both operations, and the highest grade of complication (according to the Clavien-Dindo classification) was 3A, which was observed in one patient. No 90-day mortality was observed. Radical resection (R0) was achieved in nine patients, while the resection was R2 in one patient. The low morbidity and mortality observed in this cohort compared with those of earlier reports on associating liver partition and portal vein ligation for staged hepatectomy for diagnoses other than colorectal liver metastases may be related to the selection of patients with limited comorbidity. In addition, procedures other than associating liver partition and portal vein ligation for staged hepatectomy had been avoided in most of the patients. In conclusion, associating liver partition and portal vein ligation for staged hepatectomy can be applied to primary hepatobiliary malignancies and non-colorectal liver metastases with acceptable rates of morbidity and mortality.

Does the Introduction of Laparoscopic Distal Pancreatectomy Jeopardize Patient Safety and Well-Being?

BACKGROUND/PURPOSE: Despite retrospective data indicating short-term superiority for laparoscopic distal pancreatectomy compared to open distal pancreatectomy, the implementation of the procedure has been slow. The aim of this study was to investigate whether patients operated with laparoscopic distal pancreatectomy during the early phase of introduction are at higher risk for complications than patients operated with open distal pancreatectomy. METHODS: A retrospective single-center analysis of patients operated with laparoscopic distal pancreatectomy (n = 37) from the introduction of the procedure and comparison regarding demographic data, preoperative data, operative factors, and postoperative outcomes to patients operated with open distal pancreatectomy was done. RESULTS: Operation duration shortened (195 vs 143 min, p = 0.04) and severe complications reduced (37% vs 6%, p = 0.02) significantly in the laparoscopic distal pancreatectomy group between the first half of the study and the second half. Blood loss was significantly (p < 0.001) lower in the laparoscopic distal pancreatectomy group (75 mL) than in the open distal pancreatectomy group (550 mL), while complication rate and hospital stay as well as the percentage of radical resections were the same. CONCLUSION: Laparoscopic distal pancreatectomy can be introduced without jeopardizing patient safety and well-being during the early learning curve. The procedures should be compared in a prospective randomized manner.

Associating liver partition and portal vein ligation for staged hepatectomy in patients with colorectal liver metastases--Intermediate oncological results.

BACKGROUND: Colorectal liver metastases (CRLM) not amenable for resection have grave prognosis. One limiting factor for surgery is a small future liver remnant (FLR). Early data suggests that associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) effectively increases the volume of the FLR allowing for resection in a larger fraction of patients than conventional two-stage hepatectomy (TSH) with portal vein occlusion (PVO). Oncological results of the treatment are lacking. The aim of this study was to assess the intermediate oncological outcomes after ALPPS in patients with CRLM. MATERIAL AND METHODS: Retrospective analysis of all patients with CRLM operated with ALPPS at the participating centres between December 2012 and May 2014. RESULTS: Twenty-three patients (16 male, 7 female), age 67 years (28-80) were operated for 6.5 (1-38) metastases of which the largest was 40 mm (14-130). Six (27.3%) patients had extra-hepatic metastases, 16 (72.7%) synchronous presentation. All patients received chemotherapy, 6 cycles (3-25) preoperatively and 16 (70%) postoperatively. Ten patients (43%) were rescue ALPPS after failed PVO. Severe complications occurred in 13.6% and one (4.5%) patient died within 90 days of surgery. After a median follow-up of 22.5 months from surgery and 33.5 months from diagnosis of liver metastases estimated 2 year overall survival was 59% (from surgery) and 73% (from diagnosis). Liver only recurrences (n = 8), were treated with reresection/ablation (n = 7) while lung recurrences were treated with chemotherapy. CONCLUSION: The overall survival, rate of severe complications and perioperative mortality associated with ALPPS for patients with CRLM is comparable to TSH.

Common variables in European pancreatic cancer registries: The introduction of the EURECCA pancreatic cancer project.

BACKGROUND: Quality assurance of cancer care is of utmost importance to detect and avoid under and over treatment. Most cancer data are collected by different procedures in different countries, and are poorly comparable at an international level. EURECCA, acronym for European Registration of Cancer Care, is a platform aiming to harmonize cancer data collection and improve cancer care by feedback. After the prior launch of the projects on colorectal, breast and upper GI cancer, EURECCA's newest project is collecting data on pancreatic cancer in several European countries. METHODS: National cancer registries, as well as specific pancreatic cancer audits/registries, were invited to participate in EURECCA Pancreas. Participating countries were requested to share an overview of their collected data items. Of the received datasets, a shared items list was made which creates insight in similarities between different national registries and will enable data comparison on a larger scale. Additionally, first data was requested from the participating countries. RESULTS: Over 24 countries have been approached and 11 confirmed participation: Austria, Belgium, Bulgaria, Denmark, Germany, The Netherlands, Slovenia, Spain, Sweden, Ukraine and United Kingdom. The number of collected data items varied between 16 and 285. This led to a shared items list of 25 variables divided into five categories: patient characteristics, preoperative diagnostics, treatment, staging and survival. Eight countries shared their first data. CONCLUSIONS: A list of 25 shared items on pancreatic cancer coming from eleven participating registries was created, providing a basis for future prospective data collection in pancreatic cancer treatment internationally.

The effects of omeprazole and cimetidine on duodenal ulcer healing and the relief of symptoms.

In a Swedish double-blind multicentre study, omeprazole (30 mg o.m.) was compared with the H2-receptor antagonist cimetidine (400 mg b.d.) in 152 patients. Clinical assessments and laboratory investigations were carried out at 2 and 4 weeks, and again at 6 weeks in unhealed patients. Endoscopy was performed at 2 weeks, and again at 4 and 6 weeks in unhealed patients. The patients in the two groups were well-matched prior to treatment. Omeprazole was superior to cimetidine in ulcer-healing rate after 2, 4 and 6 weeks. After 2 weeks of treatment, 66% of the omeprazole- and 45% of the cimetidine-treated patients were healed (P = 0.02), after 4 weeks 97 and 84% (P = 0.01), and after 6 weeks 100 and 92% (P = 0.02), respectively. There was a more pronounced improvement in the patients' symptoms in the omeprazole group after 2 weeks (P = 0.05). Both drugs were well-tolerated, but there was a high prevalence of patients with adverse events in the cimetidine group (51%, compared to 30% of the omeprazole group; P = 0.02). A total of 125 patients were followed for 6 months after healing. The patients were investigated by endoscopy after 6 months, or whenever symptoms occurred. There was no significant difference in the rate of relapse within 6 months between the two treatment groups: 54% relapsed in the omeprazole group and 52% in the cimetidine group. In conclusion, 30 mg of omeprazole, given once daily, is superior to 400 mg of cimetidine twice daily in duodenal ulcer healing; but ulcer relapse in the two groups appears to be equivalent.

Effect of islet amyloid polypeptide on somatostatin inhibition of insulin secretion from isolated rat pancreatic islets.

In this study, we investigated the presence of islet amyloid polypeptide (IAPP) in somatostatin cells of rat endocrine pancreas and the effect of exogenous IAPP and somatostatin, separate or combined, on in vitro insulin secretion. By immunocytochemistry, IAPP was found in both B and D cells of rat pancreatic islets. Furthermore, the labeling density of IAPP in D cells was nearly four times higher than in B cells. After a 2-day preincubation in RPMI 1640 (11.1 mM glucose), isolated rat pancreatic islets were exposed to IAPP and/or somatostatin for 90 min in modified Krebs-Ringer bicarbonate (KRB) buffers containing 11.1 or 22.2 mM glucose, or 11.1 mM glucose + 10 mM L-arginine, respectively. At 11.1 mM glucose, insulin secretion was not affected by IAPP and/or somatostatin at concentrations investigated. Insulin response to 22.2 mM glucose was inhibited by exogenous somatostatin. Arginine-stimulated insulin secretion was also inhibited by somatostatin, and the effect was significantly potentiated with additional 10(-5) M IAPP. The study shows that rat pancreatic D cells have higher IAPP density than B cells in the same islets and that IAPP and somatostatin may cooperate on rat pancreatic B cells to regulate the insulin secretion in response to potent stimulation.

Cholecystokinin octapeptide induces both proliferation and apoptosis in the rat pancreas.

Cholecystokinin-8 (CCK-8) causes exocrine pancreatic hypertrophy and hyperplasia. High doses of the CCK analogue cerulein causes necrosis and an inflammatory response in the pancreas. We have studied the pancreatic growth response in rats after administration of CCK-8 for 3 days, given either intermittently (20-80 microg/kg) twice a day, or continuously (2.4-48 microg/kg per 24 h). Plasma CCK-8 levels, pancreatic wet weight, water, protein and DNA contents and the pancreatic caspase-3 activity were measured. Cell proliferation was visualized by [3H]thymidine incorporation and apoptosis by TUNEL reaction. Continuous administration of CCK-8 dose-dependently increased the plasma CCK levels, the pancreatic wet weight, protein and DNA contents as well as thymidine labeling index, apoptotic index and caspase-3 activity. Intermittent injections of CCK-8 caused transient raises in plasma CCK, increased apoptotic index and caspase-3 activity, a dose-dependent increase in thymidine labeling but caused a dose-dependent reduction of pancreatic wet weight, protein, and DNA contents. It is concluded that CCK-8 causes both increased proliferation and apoptosis in the pancreas. In case of continuous administration of CCK-8, the proliferation outweighs the apoptosis causing hyperplasia but in the case of intermittent administration the opposite effect is seen.

Dissociated insulin and islet amyloid polypeptide secretion from isolated rat pancreatic islets cocultured with human pancreatic adenocarcinoma cells.

Abnormal insulin and islet amyloid polypeptide (IAPP) secretion are usually seen in patients with exocrine pancreatic cancer. The beta-cell dysfunction is a characteristic of the glucose intolerance found in pancreatic cancer patients. The effects of pancreatic cancer cells on insulin and IAPP secretion from beta cells are unclear. In this study, isolated rat pancreatic islets were cocultured with two human pancreatic adenocarcinoma cell lines (Panc-1 and HPAF) and a human colonic adenocarcinoma cell line (HT-29). As a control, islets were incubated in the absence of malignant cells. The accumulation of insulin and IAPP in culture media was measured by radioimmunoassay. Output of insulin and IAPP was decreased in islets cocultured with each malignant cell line. Molar ratio of secreted IAPP and insulin (IAPP/insulin) was increased in the islets cocultured with Panc-1 or HPAF cells, but not HT-29 cells. The decreased insulin and IAPP secretion were partly recovered after Panc-1, HPAF, or HT-29 cells were removed. The IAPP/insulin ratio was normalized after the removal of Panc-1 or HPAF cells. This study indicates that insulin and IAPP secretion are altered by the human adenocarcinoma cells investigated. The impairment induced by pancreatic adenocarcinoma cells is associated with a hypersecretion of IAPP relative to insulin on a molar basis.

[Guidelines for management of patients with acute pancreatitis]. / Riktlinjer för handläggning av patienter med akut pankreatit.

During recent years new concepts and methods have been introduced in the management of acute pancreatitis. Severity and risk of complications show wide variation. Outcome is also dependent on the physician's experience and on his local resources. In this light the Swedish Society of Upper Abdominal Surgery has elaborated national guidelines for management. Attention is paid to diagnosis, severity assessment and etiology. Furthermore, guidelines are offered for treatment of mild and severe pancreatitis, as well as for the management of pseudocysts. The role of multidisciplinary intensive care specialist teams in the management of severe disease is emphasized. The guidelines are supported by the Swedish Society of Gastroenterology, the Swedish Society of Gastroenterology, the Swedish Society of Anesthesiology and Intensive Care and by experts from other Nordic countries.

The importance of the centroacinar region in cerulein-induced mouse pancreatic growth.

Early proliferation events within different exocrine pancreatic cell compartments were studied in mice with or without cerulein administration. A technique with 3H-thymidine labeling of DNA-synthesizing cells was used. Groups of five animals were given either cerulein (20 micrograms/kg/24 h) or saline subcutaneously twice daily. 3H-thymidine was given as a single injection, 300 microCi intraperitoneally, on the 3rd and 8th day of cerulein or saline administration, and the fraction of labeled cells in each cell compartment (3H-thymidine labeling index, TLI) was calculated on the basis of autoradiographic analyses of the tissue. In a second set of experiments the distribution of the tracer between cell compartments, when given on the 3rd day of cerulein (saline) administration, was followed over a 5-day period. The highest proliferative rate was observed in the centroacinar cell compartment (TLI, 6%), and newly formed cells were accumulated during the 5-day 'chase' period. During the same time the relative amount of labeled centroacinar cells increased and comprised 40% of all labeled exocrine cells. The relative size of the compartment did not increase, indicating increased cell turnover with loss of or possibly migration of centroacinar cells into other pancreatic cell compartments. Weak and no trophic effects of cerulein were seen on the acinar and ductal cell populations, respectively. In the control group labeled ductal cells were significantly reduced during the chase period. This was not observed in the cerulein group, indicating addition of labeled cells to this compartment from other sources. A significant non-cerulein-dependent relative increase and decrease of the ductal and acinar cell compartments, respectively, were observed during the chase period.(ABSTRACT TRUNCATED AT 250 WORDS)

Experience of surgical treatment for chronic idiopathic constipation.

Chronic idiopathic constipation requires surgical treatment in some rare cases. Seven such patients are presented. Subtotal colectomy was performed in six of them and left hemicolectomy in one. All patients were satisfied, with 1-6 bowel movements daily, and none had complications necessitating surgery. Subtotal colectomy seems to be the preferable operation.

Proliferative response of different exocrine pancreatic cells after surgical pancreaticobiliary diversion in the rat.

Pancreaticobiliary diversion (PBD) is known to induce chronic, endogenous hypercholecystokininemia causing pancreatic growth in rats. In the present study the proliferative response of the different exocrine pancreatic cells was studied by administration of 3H-thymidine, 1 mCi/kg, given 1 h before the rats were killed and 5, 10, 20, and 40 days after PBD. DNA and 3H-thymidine uptake, both expressed per 1 mg of pancreatic tissue, were significantly increased on day 5. The nuclear labeling index was increased fivefold in both the acinar and ductal cell group. In the centroacinar cell group the labeling index was increased on day 10. In conclusion, we found that the proliferative activity after PBD occurred during the first 10 days and that the ductal cells were forced into proliferation to the same extent as the acinar ones. These findings are of interest for future studies of hormonal influences on the development of pancreatic carcinoma.

Proliferative response of different exocrine pancreatic cell types to hormonal stimuli. I. Effects of long-term cerulein administration.

The trophic effect on the exocrine pancreas of the cholecystokinin analogue cerulein was studied in a long-term experiment (20 or 160 micrograms/kg/24 h for 14 days) in mice by measuring changes in pancreatic weight and protein, amylase, and DNA content. Further, the selective cell growth stimulation exerted by various doses of cerulein (4, 20, 54, 160 micrograms/kg/24 h) on different exocrine pancreatic cell types was studied by continuous administration of 3H-thymidine. In the first experiment animals given 20 micrograms/kg/24 h of cerulein had increased pancreatic weight and amylase and protein content, whereas the animals given the higher dose had unchanged weight and a less pronounced increase in amylase and protein content. The pancreatic DNA content was unaffected in the 20-micrograms group but was clearly decreased by the higher dose. In the second experiment a statistically significant increase over controls was found in the fraction of labeled ductal cells when 20, 54, and 160 micrograms of cerulein was administered. However, in the acinar cell population an increase was measured only in the 160-micrograms group. A tendency to nadir in cell labeling was observed in both acinar and ductal cell groups at less stimulation. Labeling of centroacinar cells increased in all cerulein-treated groups. The results show that all cell types of the exocrine pancreas can be forced into proliferation by the cholecystokinin analogue used and that there is preferential cell growth stimulation in the ductal and centroacinar cell populations.

Proliferative response of different exocrine pancreatic cell types to hormonal stimuli. II. Effects of long-term secretin administration.

The effect of graded doses of secretin on exocrine pancreatic growth and cell proliferation was studied in a long-term experiment. After 16.5 and 150 micrograms/kg/24 h of secretin, each administered as two subcutaneous injections daily for 14 days, the pancreatic wet weight decreased, whereas the protein and DNA content of the gland was uninfluenced. When administered as described above for 14 days, 16.5, 50, 150, and 450 micrograms/kg/24 h of secretin did not affect the proliferation rate of ductal, acinar, or centroacinar cells as measured by a labeling index after 7 days of continuous 3H-thymidine administration. In the control groups a higher labeling index was found for ductal cells (19.9%) than for acinar cells (11.0%). During the 7 days of 3H-thymidine administration 80-90% of ductal and acinar cells remained in the G0 phase. There was a significantly higher labeling index in interlobular than in intralobular duct cells.

Cystic tumors of the pancreas.

The discovery of a cystic lesion in the pancreas implies a challenge for the physician. Approximately 10% are cystic tumors, benign to highly malignant, or true cysts, showing all stages of cellular differentiation, from benign to highly malignant tumors. Malignant cystic tumors are rare and comprise only about 1% of all pancreatic malignancies, they are potentially curable. Therefore, correct diagnosis and treatment of these lesions are of great importance. It is usually not possible to separate a pseudocyst from a benign cyst or a cystic tumor, but there are some signs and findings that could be helpful in the clinical decision. The diagnosis of a cystic pancreatic tumor requires different imaging techniques, including ultrasonography, computerized tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography, but to distinguish a pseudocyst or a benign cyst from a potentially malignant lesion can be very difficult. The usefulness of blood tests and investigations of cyst fluid can be questionable. Today, surgical treatment of cystic pancreatic tumors can be performed with low morbidity. Therefore, we conclude that an active strategy with resection of cystic tumors of the pancreas should be recommended.